Welcome to Vaya Partners

Claims Submission

• Partners Claims Submission Information (PDF)
• Home Health and Personal Care Services Claims

Physical Health

• Physical Health Service Codes and Rates
• Tailored Plan Physical Health Claims and Billing Payments 

Billing Guides

• Behavioral Health Provider Billing Guide (PDF)
• Physical Health Provider Billing Guide (PDF)

Beginning July 1, 2024

Medicaid

• Claims must be submitted within 365 days from the date of service.
• Applies to both original claim and replacement claims.
• Late submissions will be denied.

State Benefit

• Claims must be submitted within 90 days from the date of service. to ensure payment. Claims filed outside of requirement will be denied for payment.
• Replacement Claims
  • Allowed within 90 days of the processed date, not to exceed 180 days from date of service.
  • Late replacement claims will be denied.

Submission Instructions

• Send requests prior to claim submission to ClaimsDepartment@PartnersBHM.org.

Accepted Reasons for Override Requests

• Retroactive Medicaid:
  • Authorization within 90 days.
  • Submit request and claims within 90 days of NCTracks eligibility modification.
  • If claims are recouped due to retroactive Medicare or Third Party Liability (TPL):
    • The claim may be resubmitted after it has been processed by the other insurance.
    • Claims that fall outside the State benefit Fiscal Year are not eligible for resubmission.
  • Timely filing requests and claim submissions must be made within 90 days of:
    • The date the eligibility was modified in NC Tracks, OR
    • The date of the Partners recoupment.
• NC Tracks License or NPI/Taxonomy updates:
  • Submit request within 30 days of NCTracks modification.
• Alpha+ system issues identified by Partners.
• Eligibility Issues (NC Fast/NCTracks):
  • Submit request within 30 days of NCTracks eligibility update.

Providers dissatisfied with a claims outcome may submit a Claims Reconsideration Form. This serves as an informal review of the original claims determination. A claims analyst will review the submission for accuracy and issue a written research outcome.

If the provider remains dissatisfied after this process, they may file a formal grievance or complaint.

Important:
Partners has seen an increase in reconsideration requests incorrectly sent to the Provider Disputes email. This causes delays in processing. To ensure timely review:

• Do not send reconsideration requests to the disputes inbox.
• Use the Claims Reconsideration Form.
• Submit via ProviderCONNECT, secure email or other approved methods listed on the form.
• Physical Health – any reconsideration request and supporting documentation exceeding 400 pages should be mailed to:
  Partners Health Management
  P.O. Box 8002
  Farmington, MO 63640-8002

What can be reconsidered?
Participating and out-of-network providers may request a review of:

• Program integrity-related findings or activities
• Waste or abuse findings by Partners
• Recovery of overpayments
• Withholding or suspension of payments
• Contract termination or non-renewal (e.g., Local Health Department services)
• Decertification of Advanced Medical Home+ or CMA (Medicaid only)
• Violations of contract terms
• Out-of-network payment arrangements

Deadlines and Extensions:

• Requests must be submitted within 30 calendar days of receiving written notice or from the date an expected action was not taken.
• Partners may extend the deadline by 30 days for good cause, such as time needed to gather supporting documentation.
• If a provider does not submit the request within the required timeframe, the decision becomes final.

Documentation:
The form collects details such as:

• Nature of the issue
• Past resolution attempts
• Supporting documentation

Original documents should not be submitted unless requested. Partners is not obligated to return any materials unless previously agreed upon in writing.

Grievance/Complaint Process

• If still dissatisfied after reconsideration, providers may File a Grievance/Complaint.

• Partners Reconsideration Form
• Partners Coordination of Benefits
• Medicare/Third Party Liability Bypass Codes
• UB04 Instruction Guide
• Download Q Instruction Guide
• Frequently Asked Questions
• Known Issues Tracker

Note:
The Alpha+ Provider Portal Manual outlines detailed instructions for completing a claims form. Additional information is available in the Partners Provider Operations Manual.